A 50-year-old man comes to the emergency department due to acute onset respiratory difficulty. He also has periorbital, circumoral and facial edema. He denies any itching or skin rash. Two weeks ago, he experienced chest pain, profuse sweating and anxiety, and was subsequently admitted to the cardiac intensive care unit. At that time, his ECG showed ST segment elevation and Q waves in the inferior leads. He was taken to the catheterization lab and had an angioplasty with stent done for 100% occlusion of the right coronary artery. He was discharged with the following medications: aspirin, clopidogrel, metoprolol, enalapril, simvastatin and isosorbide mononitrate. In the ED, his pulse is 102/min, blood pressure is 110/70 mmHg, respirations are 24/min and temperature is 36.8°C (98.4°F). Which of the following is most likely responsible for his present symptoms?

Question

A 50-year-old man comes to the emergency department due to acute onset respiratory difficulty.  He also has periorbital, circumoral and facial edema. He denies any itching or skin rash. Two weeks ago, he experienced chest pain, profuse sweating and anxiety, and was subsequently admitted to the cardiac intensive care unit.  At that time, his ECG showed ST segment elevation and Q waves in the inferior leads.  He was taken to the catheterization lab and had an angioplasty with stent done for 100% occlusion of the right coronary artery.  He was discharged with the following medications: aspirin, clopidogrel, metoprolol, enalapril, simvastatin and isosorbide mononitrate.  In the ED, his pulse is 102/min, blood pressure is 110/70 mmHg, respirations are 24/min and temperature is 36.8°C (98.4°F).  Which of the following is most likely responsible for his present symptoms?

Quizplus · Accepted Answer

ACE inhibitors are the most common cause of acquired angioedema. Patients present with edema in the face, mouth, lips, tongue, glottis and larynx. Laryngeal edema can cause airway obstruction and be life threatening. Angioedema occurs due to the pro-inflammatory action of bradykinin, which promotes edema, inflammation and the sensation of pain. Angiotensin converting enzyme (ACE) is also known as kininase; it functions to degrade bradykinin. When ACE is inhibited, levels of bradykinin increase, thereby leading to angioedema. ACE inhibitors are usually started on the first post-infarction day in non-hypotensive patients, and patients typically present with angioedema within days to weeks after starting therapy (as in this patient). However, it is important to note that angioedema from ACE inhibitors can occur at ANYTIME, not just within weeks of starting the medication. The first step in management of angioedema is to check for airway compromise and vasomotor instability, which require subcutaneous epinephrine administration if present. If airway obstruction fails to respond to epinephrine, an emergency tracheostomy is done. The ACE-inhibitor should be stopped immediately. (Choice A) The common adverse effects of beta-blockers (metoprolol) are bradycardia, AV block, bronchoconstriction (clinically significant in patients with asthma and COPD), and male sexual dysfunction. (Choice B) Nitrates can cause headaches, hypotension and development of tolerance to the drug with continuous use. (Choice C) Clopidogrel uncommonly causes adverse reactions, the most significant of which is thrombotic thrombocytopenic purpura. (Choice D) Aspirin and NSAIDs can cause allergic angioedema. It typically happens immediately after exposure and it is accompanied by itching and skin rash (urticaria). (Choice F) Statins are associated with hepatotoxicity and myopathy. Educational objective: ACE inhibitors are the most common cause of acquired angioedema. It is important to note that angioedema from ACE inhibitors can occur at ANYTIME, not just within weeks of starting the medication. Other adverse effects of ACE inhibitors are cough, hyperkalemia, and precipitation of acute renal failure in patients with bilateral renal artery stenosis. References: Angiotensin-converting enzyme inhibitors and angioedema. (http://www.ncbi.nlm.nih.gov/pubmed/20592919)

A 50-Year-Old Man Comes to the Emergency Department Due to Acute